St. Croix Hospice

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; [and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, document review, observation, and interview. Agency policy #2-004 “Medication Profile” (Last Review Date: 03/20/2024) read in part, “The medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications... A drug regimen review will be performed at the time of the initial and comprehensive assessment, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication...During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure the patient and family/caregiver, as well as other clinicians understand the medication regimen.” In 2 of 19 (11%) clinical records reviewed and home visits observed, the agency did not ensure that the drug profile contained the patient’s current prescription drugs. Clinical Record 2/Home Visit 2: The patient elected hospice care on 03/25/2024. During the home visit on 05/29/2024 with the Registered Nurse (RN) [Personnel Record 3], the hospice medication profile was reconciled with the medications in the home at the time of the visit. The medication profile documented, “Clonazepam 5mg one (1) po once a day at bedtime (qhs).” Clonazepam was not present in the patient’s home. The caregiver stated that the patient had stopped the medication “a long time ago” due to side effects and was using it on an as needed basis per physician instruction. The RN [Personnel Record 3] replied that the medication was no longer daily but “as needed” which was not documented on the medication profile at the time of the visit nor at the time of the record review on 05/29/2024. Clinical Record 15: The patient elected hospice care on 04/02/2024. On 04/24/2024 the physician ordered: “Macrobid 100mg one (1) capsule 2 times/day x 7 days.” As of 05/28/2024, Macrobid was an active medication on the medication profile and had not been discontinued upon completion of the seven-day order. During an interview on 05/31/2024, the Manager of Accreditation reviewed the associated records and stated that the medication profiles had since been updated to reflect the current medications.”

“It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #9-017 “The Plan of Care” (Last Review Date: 02/14/2024) read in part, “12.The written plan of care will contain, but not be limited to the following: S, Drugs and ‘treatments...” In 3 of 19 (16%) clinical records reviewed, the agency did not ensure that the patient’s written plan of care included all of the treatments necessary to meet the needs of the patient. Clinical Record 2: The patient elected hospice care on 03/25/2024. The initial comprehensive assessment completed by the Registered Nurse on 03/25/2024 documented that the patient had a colostomy and urostomy. A review of the clinical record on 05/29/2024 revealed that the initial plan of care and hospice plan of care dated 03/30/2024 did not include documentation for the care and management of the colostomy and urostomy. Clinical Record 15: The patient elected hospice care on 04/02/2024. The hospice plan of care dated 04/02/2024 ordered: “Patient to self cath every 6 hours as needed.” A review of the clinical record on 05/28/2024, revealed that the 04/02/2024 initial and the 04/04/2024, 04/18/2024, and 05/02/2024 updated hospice plans of care did not include the catheter size or instructions for the “as needed” self-catheterization. Clinical Record 19: The patient elected hospice care on 11/16/2023 and resided in a Skilled Nursing Facility (SNF). The initial comprehensive assessment completed by the RN on 11/16/2023 documented that the patient had the diagnosis of “Type II diabetes mellitus (DM),” and had Accu-Chek monitoring two times a day “(bid) by Facility Staff.” The hospice plans of care dated 02/14/2024, 02/22/2024, 03/07/2024, 03/21/2024, 04/04/2024, 04/18/2024, and 05/01/2024 did not document Accu-Chek monitoring and management instructions. The plans of care documented the patient’s diagnosis of “Type II DM” diagnosis and ordered “Levemir 100u/ml 30U SQ qhs.” During an interview on 05/31/2024, the Manager of Accreditation reviewed the associated records and stated that the plans of care had been reviewed and corrections had since been made to the orders/plans of care.”

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient’s condition requires; but no less frequently than every 15 calendar days. A revised plan of care must include information from the patient’s updated comprehensive assessment and must note the patient’s progress toward outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #9-017 “Plan of Care” (Last Review Date: 02/14/2024) read in part, “Each patient will be monitored for his/her response to care or services provided against established patient goals and patient outcomes to evaluate progress toward goals...Care decisions and services to be provided will be made as a result of the care planning process, analysis of initial and ongoing comprehensive assessments, and analysis of patient response to care against goals and outcomes...The plan of care will be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days, by the interdisciplinary group, with input from the attending physician, the patient, and the family/caregiver. Review of the plan of care will be documented in the clinical record. Revision dates will be noted on the plan of care...” In 6 of 19 (32%) clinical records reviewed, the agency did not ensure that the patient’s revised plan of care included information from the patient’s updated comprehensive assessment. Clinical Record 1: The patient elected hospice care on 01/26/2024. The initial Social Work (MSW) and Spiritual Care (SC) evaluations and plans of care were completed on 01/30/2024. The hospice plan of care dated 03/26/2024 ordered MSW services “2xMTHx2” and SC services “1xMTHx2 effective 04/01/2024.” The 03/21/2024 interdisciplinary team meeting and updated assessments documented the plan to continue MSW and SC interventions and goals into the next certification period due to continued psychosocial and spiritual needs. At the time of the review on 05/29/2024, the updated MSW and SC interventions were not documented on the 03/26/2024 plan of care. Clinical Record 2: The patient elected hospice care on 03/25/2024. The initial MSW and SC evaluations and plans of care were dated as completed on 03/25/2024. The hospice plan of care dated 03/30/2024 ordered MSW services “2xMTHx1 effective 04/01/2024” and SC services “1xMTHx1 effective 04/21/2024.” The 04/04/2024 interdisciplinary team meeting and updated assessments documented the plan to continue MSW and SC interventions and goals into the next certification period due to continued psychosocial and spiritual needs. At the time of the review on 05/29/2024, the updated MSW and SC interventions were not documented on the 03/30/2024 plan of care. Clinical Record 3: The patient elected hospice care on 01/04/2024. The initial MSW and SC evaluations and plans of care were dated as completed on 01/08/2024 and 01/05/2024, respectively. The hospice plan of care dated 05/03/2024 ordered MSW services “2xMTHx2” and SC services “5xMTHx1, 4xMTHx1.” The 05/03/2024 interdisciplinary team meeting and updated assessments documented the plan to continue MSW and PC interventions and goals into the next certification period due to continued psychosocial and spiritual needs. At the time of the review on 05/29/2024, the updated MSW and SC interventions were not documented on the 05/03/2024 plan of care. Clinical Record 4: The patient elected hospice care on 12/26/2023. The initial MSW and SC evaluations and plans of care were dated as completed on 12/29/2023 and 12/28/2023, respectively. The hospice plan of care dated 03/25/2024 ordered MSW services “1xMTHx3, effective 04/01/2024” and SC services “1xMTHx3 effective 04/01/2024.” The 03/21/2024 interdisciplinary team meeting and updated assessments documented the plan to continue MSW and PC interventions and goals into the next certification period due to continued psychosocial and spiritual needs. At the time of the review on 05/29/2024, the updated MSW and SC interventions were not documented on the 03/25/2024 plan of care. Clinical Record 11: The patient elected hospice care on 02/01/2024. The initial MSW and SC evaluations and plans of care were dated as completed on 02/05/2024 and 02/02/2024, respectively. The hospice plan of care dated 05/01/2024 ordered MSW services “2xMTHx3” and SC services “1xMTHx3 effective 05/01/2024.” The 04/18/2024 interdisciplinary team meeting and updated assessments documented the plan to continue MSW and PC interventions and goals into the next certification period due to continued psychosocial and spiritual needs. At the time of the review on 05/29/2024, the updated MSW and SC interventions were not documented on the 05/01/2024 plan of care. Clinical Record 12: The patient elected hospice care on 01/23/2024. The initial MSW and SC evaluations and plans of care were dated as completed on 01/26/2024 and 02/02/2024, respectively. The hospice plan of care dated 04/22/2024 ordered MSW services “2xMTHx3” and SC services “1xMTHx3, effective 05/01/2024.” The 04/18/2024 interdisciplinary team meeting and updated assessments documented the plan to continue MSW and PC interventions and goals into the next certification period due to continued psychosocial and spiritual needs. At the time of the review on 05/30/2024, the updated MSW and SC interventions were not documented on the 04/22/2024 plan of care. During an interview on 05/31/2024, the Manager of Accreditation reviewed the associated records and stated the plans of care have since been updated to reflect current interventions and goals.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum physician orders. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed the agency did not ensure the record contained complete physician orders. Clinical Record 9: The patient elected hospice care on 04/30/2024. On 05/02/2024, the physician ordered: “Hospice RN to provide care on visit days and Facility RN to provide care on all other days, cleanse area with wound cleanser and apply Flanders three times a day (tid) and pro re nata/as needed (prn) for soilage.” A review of the clinical record on 05/30/2024 revealed the order did not document the wound location. On 05/12/2024, the physician ordered: “Hospice RN to cleanse wound left heel, pat dry, apply foam dressing and heel protector, change 2xweek and prn for discomfort.” A review of the clinical record on 05/30/2024 revealed the order did not document the wound cleanser. Clinical Record 19: The patient elected hospice care on 11/16/2023. The hospice plan of care dated 02/14/2024 ordered skilled nursing services “1 week 13.” For the week of 02/20/2024 there were two (2) visits documented dated 02/20/2024 and 02/22/2204. A review of the clinical record review on 05/30/2024 revealed no evidence of communication with the physician or a physician supplemental order for the visit frequency provided. During an interview on 05/31/2024, the Manager of Accreditation reviewed the associated record and stated that there was a “clerical error” and the error had since been corrected.”

“It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 13 (15%) clinical records reviewed of patients residing in a Skilled Nursing Facility (SNF), the agency did not ensure that the hospice plan of care identified the care and services that were needed, and specified which provider was responsible for performing the functions. Clinical Record 14: The patient elected hospice care on 04/05/2024 and resided in a SNF. The supplemental physician’s order dated 05/08/2024 entered by the RN ordered “cleanse wound to right buttock with soap and water daily and prn soilage, pat dry, apply thin layer of 100% Medi homey to open area- Hospice nurse to assess weekly.” The order did not specify which provider was to provide the wound care. Clinical Record 19: The patient elected hospice care on 11/16/2023 and resided in a Skilled Nursing Facility (SNF). The initial comprehensive assessment completed by the RN on 11/16/2023 documented that the patient had the diagnosis of “Type II diabetes mellitus (DM),” and had Accu-Chek monitoring two times a day “(bid) by Facility Staff.” The hospice plans of care dated 02/14/2024, 02/22/2024, 03/07/2024, 03/21/2024, 04/04/2024, 04/18/2024, and 05/01/2024 did not document Accu-Chek monitoring and management instructions and which provider was responsible for performing the functions. The plans of care documented the patient’s diagnosis of “Type II DM” diagnosis and ordered “Levemir 100u/ml 30U SQ qhs.” During an interview on 05/31/2024, the Manager of Accreditation reviewed the associated records and stated that the delineation of duties for each provider had since been verified and the plans of care corrected.”